on clients letterhead

CLIENT INFORMATION SHEET

In accordance with the Patriot Act of October 26, 2001, and amendments thereto; Articles 2 and 5 of the Due Diligence and Federal Banking Commission Circular of December 1999 and its amended articles, concerning the prevention of money laundering, and Article 305 of the Swiss Criminal Code, the following information may be supplied to banks and to financial institutions for purposes of verification and identification regarding these matters.

All parties are obligated to respect professional secrecy and take all appropriate precautions to protect the confidentiality of the information it holds in respect of their activities per the NC/ND agreement. This legal obligation shall remain in effect at all times.

The below information is needed for each Signatory Control

Date of Information:

1. Client Information

a. Client Name:

b. Nationality:

c. Passport

i. Number:

ii. Date of Issue:

iii. Expiration Date:

iv. Issued by:

d. Passport

i. Number:

ii. Date of Issue:

iii. Expiration Date:

iv. Issued by:

e. Date and Place of Birth:

f. Home Address (please provide if not same as business)

i. Street:

ii. City:

iii. State:

iv. Postal Code:

v. Home Telephone No.:

vi. Cellular No.:

vii. Home Fax No.:

viii. Email (copy 1):

ix. Email (copy 2):

2. Business Information: Please provide a current Certificate of Good Standing from the State/Country where the Corporation/Business Entity was Incorporated/Formed.

a. Business Name:

b. TIN/EIN:

c. Registration Office:

d. Registered Address:

i. Street:

ii. City:

iii. State:

iv. Postal Code:

e. Business Telephone No.:

f. Business Fax No.:

g. Business Email (copy 1):

h. Business Email (copy 2):

3. Legal Advisor/Mandate (if none please state):

a. Name:

b. Company Name:

c. Company Address

i. Street:

ii. City:

iii. State:

iv. Postal Code:

d. Company Phone No.:

e. Company Fax No.:

f. Email (copy 1):

g. Email (copy 2):

4. Principal Funds Information

a. Amount of Funds:

b. Currency (3 digit ID):

c. Date Funds were transferred into Account:

d. Bank where Funds are on deposit:

e. Bank Address:

f. Bank Officer Name:

g. Account Name:

h. Account Number:

i. Bank SWIFT/ABA No.:

j. Account Signatory:

k. Are Funds free and clear without liens:

i. If Funds have not been in the above account for three (3) years or more please list previous accounts

1. Amount of Funds:

2. Currency (3 digit ID):

3. Date Funds were transferred into Account:

4. Bank Name where Funds were:

5. Bank Address:

6. Bank Officer Name:

7. Account Name:

8. Account Number:

9. Bank SWIFT/ABA No.:

10. Account Signatory:

Certification

1. There are no affiliates of Applicant who will benefit from this transaction, nor any interrelated parties that could affect the outcome of this contemplated transaction.

2. Applicant hereby declares that the undersigned is the Authorized Signatory or owner of the Funds, or the duly appointed representative with full Signatory power on the bank account to transfer, assign, pledge or reserve the cash upon terms satisfactory to Applicant, further that vested with fully authority to execute all documents and agreements relating to the same. (Please provide Corporate Resolution in Attachment 8 signed and sealed.)

3. Applicant hereby grants permission to contact all parties and institutions named within this document including the Authorization to Verify Funds (Attachment 9) at Applicant’s Bank.

I hereby swear, under penalty of perjury, the information given hereon is accurate and true.

_____________________

(Signature)

NAME: – TITLE